Job Description
Job Title

Clinical Investigator

Experience

- 1+ Year of relevant experience for non-medical graduates
- Medical graduates with relevant coding experience can be considered as per eligibility

Qualification

- Any Graduate
- BHMS / BAMS / BUMS / BPT / MPT Preferred
- B. Sc. Nursing / BDS

Certification

- AAPC Certification Mandatory
- CPC Only accepted certification

Role Overview

We are looking for a Clinical Investigator to support healthcare claims investigation, review, recovery, and resolution activities. The role involves reviewing claims using medical knowledge, CPT and diagnosis coding expertise, applicable coding guidelines, client-specific guidelines, and member policies to identify potentially fraudulent or abusive claims and ensure accurate claim outcomes.

The candidate should have strong analytical, comprehension, and attention-to-detail skills, with the ability to work independently and handle assignments that may not always have established procedures.

Required Skills

- Strong knowledge of Medical Coding and Healthcare Claims
- Knowledge of CPT and Diagnosis Codes
- Understanding of US Healthcare
- Medical record review and familiarity
- Strong analytical and comprehension skills
- Excellent attention to detail and quality orientation
- Ability to work independently
- Ability to investigate and analyze complex claims
- Positive communication and problem-solving skills

Required Experience

For non-medical graduates, minimum 1+ year of specialty medical coding experience is required, such as:

- E&M; Coding
- ED Coding
- Surgery Coding
- Anesthesia Coding
- Other specialty coding

HCC-only coding experience is not considered sufficient.





Key Responsibilities

- Investigate and review healthcare claims to identify potentially fraudulent and/or abusive claims.
- Utilize medical expertise and knowledge of CPT and diagnosis codes during claim investigations.
- Apply applicable coding guidelines, client-specific guidelines, reimbursement policies, and member policies.
- Investigate, recover, and resolve various types of claims and recovery-related activities.
- Support claim recovery and resolution for health plans, commercial customers, and government entities.
- Conduct medical history reviews and contestable investigations where required.
- Support coordination of benefits activities and gather relevant information from members, providers, and other insurance entities when required.
- Investigate and pursue recoveries and payables related to subrogation claims and file management.
- Monitor and review large claims, including complex cases such as transplant claims, where applicable.
- Ensure adherence to state and federal regulations, reimbursement policies, and contract compliance.
- Assist with special projects, reporting, and process improvement initiatives.
- Work independently on assignments and act as a resource for team members when required.




- Coordinate activities with other team members and support overall process objectives.

Preferred Qualifications

- Experience in Claims Processing
- Knowledge of Health Insurance / Managed Care
- Experience with US Healthcare and Medical Coding
- Familiarity with Medical Records
- Experience in claims investigation, recovery, or resolution

VDart: Digital Consulting & Staffing Solutions

VDart is a leading digital consulting and staffing company founded in 2007 and headquartered in Alpharetta, Georgia. VDart is one of the top staffing companies in USA & also provides technology solutions, supporting businesses in their digital transformation journey. Digital consulting services, Digital consulting agency

Core Services:

- Digital consulting and transformation solutions
- Comprehensive staffing services (contract, temporary, permanent placements)
- Talent management and workforce solutions
- Technology implementation services

Key Industries: VDart primarily serves industries such as automotive and mobility, banking and finance, healthcare and life sciences, and energy and utilities. VDart - Products, Competitors, Financials, Employees, Headquarters Locations

Notable Partnership: VDart Digital has been a consistently strong supplier for Toyota since 2017 Digital Transformation Consulting & Strategy Services | VDart Digital, demonstrating their capability in large-scale digital transformation projects.

With over 17 years of experience, VDart combines staffing expertise with technology solutions to help organizations modernize their operations and build skilled workforce capabilities across multiple sectors.

📌 Clinical Investigator - Chennai (India)
🏢 VDart Software Services
📍 India